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Small Intestine James Lee. Which of the following is the principal fuel used by the small intestine? A.Arginine B.Alanine C.Glutamine D.Tyrosine E.Carnitine.

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Presentation on theme: "Small Intestine James Lee. Which of the following is the principal fuel used by the small intestine? A.Arginine B.Alanine C.Glutamine D.Tyrosine E.Carnitine."— Presentation transcript:

1 Small Intestine James Lee

2 Which of the following is the principal fuel used by the small intestine? A.Arginine B.Alanine C.Glutamine D.Tyrosine E.Carnitine

3 Which of the following is the principal fuel used by the small intestine? A.Arginine B.Alanine C.Glutamine D.Tyrosine E.Carnitine Glutamine is the principal fuel of the small intestine

4 A pt. with liver mets related to small bowel carcinoid tumor develops flushing and diarrhea. These symptoms are most likely caused by: A.Epinephrine B.Serotonin C.Bradykinin D.ACTH

5 A pt. with liver mets related to small bowel carcinoid tumor develops flushing and diarrhea. These symptoms are most likely caused by: A.Epinephrine B.Serotonin C.Bradykinin D.ACTH Serotonin is released from carcinoid tumors If mets to liver, serotonin not metabolized Can measure 5-HIAA in urine

6 2 years after resection of a small bowel carcinoid with isolated liver mets, the patient develops vague abdominal complaints, but no new lesions are identified on CT scan. What is the best study to look for recurrent carcinoid tumor? A.HIDA scan B.MIBG scan C.Octreotide scan D.MRI

7 2 years after resection of a small bowel carcinoid with isolated liver mets, the patient develops vague abdominal complaints, but no new lesions are identified on CT scan. What is the best study to look for recurrent carcinoid tumor? A.HIDA scan B.MIBG scan C.Octreotide scan D.MRI Octreotide scan is the most sensitive diagnostic test for the detection of a carcinoid tumor not apparent on CT scan

8 You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 1 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is: A.Right hemicolectomy B.Close observation C.Post-op radiation D.Post-op chemo

9 You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 1 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is: A.Right hemicolectomy B.Close observation C.Post-op radiation D.Post-op chemo Appendectomy is adequate treatment for carcinoid tumors localized to the appendix if < 2 cm, not at base, and no evidence of metastatic disease

10 You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 2.5 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is: A.Right hemicolectomy B.Close observation C.Post-op radiation D.Post-op chemo

11 You perform an appendectomy on a 25 YO man for presumed appendicitis and find a 2.5 cm tumor at the tip of the appendix. Pathology returns as carcinoid. The most appropriate next step in management is: A.Right hemicolectomy B.Close observation C.Post-op radiation D.Post-op chemo If carcinoid is > 2 cm or not at tip, perform Right hemicolectomy

12 The most common cardiac valvular lesion associated with carcinoid syndrome is: A. Tricuspid stenosis B. Tricuspid insufficiency C. Pulmonary stenosis D. Pulmonary insufficiency E. Mitral stenosis

13 The most common cardiac valvular lesion associated with carcinoid syndrome is: A. Tricuspid stenosis B. Tricuspid insufficiency C. Pulmonary stenosis D. Pulmonary insufficiency E. Mitral stenosis Most common valvular disorder is tricuspid insufficiency Vasoactive substances are released from liver mets and transported to R heart  endocardial damage  thickening/retraction/fixation of valves Pulmonary valve lesions next most common

14 A 46-year-old woman is about to undergo hepaticresection for a metastatic carcinoid tumor. During induction, SBP falls to 80 mm Hg and heart rate increases to 110 beats/min. Her entire body appears flushed. Her temperature is normal as is end-tidal CO2. Management consists of: A.Corticosteroids B.Antihistamine C.Octreotide D.Abort operation E.Dantrolene

15 A 46-year-old woman is about to undergo hepaticresection for a metastatic carcinoid tumor. During induction, SBP falls to 80 mm Hg and heart rate increases to 110 beats/min. Her entire body appears flushed. Her temperature is normal as is end-tidal CO2. Management consists of: A.Corticosteroids B.Antihistamine C.Octreotide D.Abort operation E.Dantrolene The pt. has carcinoid crisis Carcinoid crisis characterized by hypotension, bronchospasm, flushing, and tachycardia Primary treatment is IV octreotide administered as a bolus of pg

16 You perform laparoscopy on a 25 YO M for presumed appendicitis and find non obstructing terminal ileitis not involving the cecal area. The most appropriate next step in management is: A.Appendectomy B.Close observation C.Place a drain D.Ileal resection

17 You perform laparoscopy on a 25 YO M for presumed appendicitis and find non obstructing terminal ileitis not involving the cecal area. The most appropriate next step in management is: A.Appendectomy B.Close observation C.Place a drain D.Ileal resection If cecum not involved perform appendectomy so that confusion of ileitis with appendicitis will not occur in the future If cecum involved leave appendix b/c high risk for leak

18 Concerning short gut syndrome, all of the following are true except: A.This is a clinical diagnosis of inability to absorb enough water and nutritional elements to be off TPN B.The length of bowel in general needs to be at least 75 cm if there is no ileocecal valve C.The length of bowel in general needs to be at least 50 cm if there ileocecal valve present D.The length of bowel needs to be at least 150 cm if there is no ileocecal valve

19 Concerning short gut syndrome, all of the following are true except: A.This is a clinical diagnosis of inability to absorb enough water and nutritional elements to be off TPN B.The length of bowel in general needs to be at least 75 cm if there is no iliocecal valve C.The length of bowel in general needs to be at least 50 cm if there iliocecal valve present D.The length of bowel needs to be at least 150 cm if there is no iliocecal valve In general the length of bowel needs to be at least 50 cm with iliocecal valve and at least 75 cm w/o iliocecal valve to avoid TPN

20 A 75 YO M on NSAIDs for arthritis presents with a 6 hr h/o abdominal pain and is found to have an acute abdomen with pneumoperitoneum. His vital signs stabilize after 2 L crystalloid. What should be the next step in management? A.Operation B.EGD C.UGI D.Antisecretory drugs, antibiotics for H. pylori, and operation if he fails to improve in 6 hrs

21 A 75 YO M on NSAIDs for arthritis presents with a 6 hr h/o abdominal pain and is found to have an acute abdomen with pneumoperitoneum. His vital signs stabilize after 2 L crystalloid. What should be the next step in management? A.Operation B.EGD C.UGI D.Antisecretory drugs, antibiotics for H. pylori, and operation if he fails to improve in 6 hrs Preferred treatment of perforated duodenal ulcer is resuscitation and prompt operation Non op management is reserved for old contained perforations or terminally ill pts. who cannot undergo surgery

22 What operation would you perform on the 75 YO M on NSAIDs for arthritis pt. with a perforated duodenal ulcer? A.Suture closure of the perforation B.Omental patch of perforation C.Repair of perforation and highly selective vagotomy D.Repair of perforation and truncal vagotomy E.Repair of perforation and gastric resection

23 What operation would you perform on the 75 YO M on NSAIDs for arthritis pt. with a perforated duodenal ulcer? A.Suture closure of the perforation B.Omental patch of perforation C.Repair of perforation and highly selective vagotomy D.Repair of perforation and truncal vagotomy E.Repair of perforation and gastric resection Closure of the perforation is best accomplished with a Graham patch: 1/3 no recurrence; 1/3 recurrence amenable to medical management; 1/3 recurrence requiring surgery Definitive operations should only be performed on stable patients Hold ulcerogenic drugs and treat H. pylori following surgery

24 With regard to duodenal ulcer complicated by hemorrhage which of the following statements are true? A.It is a more common complication of duodenal ulcer than perforation B.Endoscopic treatment before operation decreases mortality C.Endoscopic treatment decreases the need for operation D.Operative management is indicated only if endoscopic treatment fails E.Operative management should include an acid-reducing procedure

25 With regard to duodenal ulcer complicated by hemorrhage which of the following statements are true? A.It is a more common complication of duodenal ulcer than perforation B.Endoscopic treatment before operation decreases mortality C.Endoscopic treatment decreases the need for operation D.Operative management is indicated only if endoscopic treatment fails E.Operative management should include an acid-reducing procedure Hemorrhage is the most common complication of duodenal ulcer Most important endoscopic predictor of persistent/recurrent bleeding is active arterial spurting; presence of visibile vessel implies high risk of recurrent bleeding A definitive antiulcer operation should be performed b/c high risk of recurrent bleeding: If in shock/ill - truncal vagotomy/pyloroplasty Otherwise parietal cell vagotomy or truncal vagotomy and antrectomy

26 Which of the following conditions is/are associated with an increased risk of duodenal adenocarcinoma? A.Heterotopic pancreas B.Adenoma of Brunner’s glands C.Nodular hyperplasia of Brunner’s glands D.Gardner’s syndrome E.Familial polyposis coli

27 Which of the following conditions is/are associated with an increased risk of duodenal adenocarcinoma? A.Heterotopic pancreas B.Adenoma of Brunner’s glands C.Nodular hyperplasia of Brunner’s glands D.Gardner’s syndrome E.Familial polyposis coli Adenocarcinoma is the most common malignant duodenal neoplasm A/W adenomatous polyps, villous adenomas, familial polyposis coli, Gardner’s syndrome, von Recklinghausen’s disease

28 Which of the following conditions is not associated with an increased risk of small bowel malignancy? A.Celiac disease B.Crohn’s disease C.Scleroderma D.Familial adenomatous polyposis E.PJS

29 Which of the following conditions is not associated with an increased risk of small bowel malignancy? A.Celiac disease B.Crohn’s disease C.Scleroderma D.Familial adenomatous polyposis E.PJS ↑ lymphoma, esophageal CA, small bowel adenocarcinoma in celiac disease ↑ risk factors in Crohn’s for adenocarcinoma ↑ adenomas in FAP ↑ hamartomatous polyps in PJS

30 What is the most common primary surgical disease of the small bowel?

31 Crohn’s disease

32 What is the most common reason to operate on a patient with Crohn’s disease?

33 Small bowel obstruction

34 What is the most important hormone in migrating motor complex?

35 Motilin

36 In regards to MMC, what happens during: Phase I: Phase II: Phase III: Phase IV: Rest Acceleration and Gall bladder contraction Peristalsis Deceleration

37 What is the most common cause of a small bowel obstruction in a patient without previous surgery?

38 Hernia

39 What is the #1 cause of SBO in children?

40 Hernia

41 What is the #1 cause of SBO in the world?

42 Hernia

43 What is the most common cause of a small bowel obstruction in a patient that has had previous surgery?

44 Adhesions

45 A hernia sac containing a Meckel diverticulum is known as?

46 Littre hernia

47 What syndrome is characterized by vascular compression of the duodenum?

48 Wilkie’s syndrome (SMA syndrome)

49 What portion of the duodenum is compressed by the SMA with Wilkie’s syndrome?

50 3 rd portion of duodenum

51 The SMA (Wilkie) syndrome: A. Involves the second portion of the duodenum B. Is more common in men C. Is best diagnosed with arteriography D. Is associated with body casting E. Is best managed by gastrojejunostomy

52 The SMA (Wilkie) syndrome: A. Involves the second portion of the duodenum B. Is more common in men C. Is best diagnosed with arteriography D. Is associated with body casting E. Is best managed by gastrojejunostomy SMA syndrome more common in women Dx can best be made by a CT (decreased aortomesenteric angle and decreased distance b/t aorta and SMA, and duodenal obstruction) Predisposing factors include supine immobilization, scoliosis, placement of a body cast, and eating disorders Conservative measures tried first

53 Operative treatment of choice for pt. with Wilkie’s syndrome refractory to conservative management?

54 Duodenojejunostomy

55 What is the strongest layer of the small bowel?

56 Submucosa

57 What is the most common presentation of Meckel’s diverticulum in adults? A. Occult bleeding B. Massive lower GI bleed C. Diverticulitis with abscess D. Diverticulitis with diffuse peritonitis E. Obstruction

58 What is the most common presentation of Meckel’s diverticulum in adults? A. Occult bleeding B. Massive lower GI bleed C. Diverticulitis with abscess D. Diverticulitis with diffuse peritonitis E. Obstruction Volvulus of small bowel around diverticulum; intussusception; incarceration into hernia

59 Most common presentation for Meckel’s diverticulum in children is? A.Intussusception B.GI bleeding C.Incarceration into a hernia sac D.Diverticulitis E.Obstruction caused by volvulus

60 Most common presentation for Meckel’s diverticulum in children is? A.Intussusception B.GI bleeding C.Incarceration into a hernia sac D.Diverticulitis E.Obstruction caused by volvulus Meckel’s also most common cause of lower GI bleeding in children

61 A 12-year-old boy presents with a large amount of bright red blood per rectum, combined with melena. He is hemodynamically stable. Subsequent work-up includes lower and upper endoscopies, both of which are negative. A technetium-99m pertechnetate nuclear scan is performed and lights up in the in the right lower quadrant. Further management consists of: A. Arteriography B. Meckel diverticulectomy C. Small bowel follow-through D. Segmental resection of ileum to include the Meckel diverticulum E. CT scan of the abdomen with oral contrast

62 A 12-year-old boy presents with a large amount of bright red blood per rectum, combined with melena. He is hemodynamically stable. Subsequent work-up includes lower and upper endoscopies, both of which are negative. A technetium-99m pertechnetate nuclear scan is performed and lights up in the in the right lower quadrant. Further management consists of: A. Arteriography B. Meckel diverticulectomy C. Small bowel follow-through D. Segmental resection of ileum to include the Meckel diverticulum E. CT scan of the abdomen with oral contrast The gastric mucosa secretes acid  ulcer formation & bleeding Usually in adjacent ileum and not in Meckel diverticulum itself Specimen should be opened to search for ulceration

63 A 5-year-old boy presents with symptoms and signsof acute appendicitis. He undergoes an open appendectomy. At surgery, the appendix is acutely inflamed but not perforated. A Meckel diverticulum is incidentally discovered. In addition to performing an appendectomy, further management consists of: A. Observation B. Meckel diverticulectomy C. Meckel diverticulectomy only if ectopic mucosa is palpated in the diverticulum D. Meckel diverticulectomy only if an adhesive band to the umbilicus is present E. Meckel diverticulectomy only if previous signs of inflammation are present

64 A 5-year-old boy presents with symptoms and signsof acute appendicitis. He undergoes an open appendectomy. At surgery, the appendix is acutely inflamed but not perforated. A Meckel diverticulum is incidentally discovered. In addition to performing an appendectomy, further management consists of: A. Observation B. Meckel diverticulectomy C. Meckel diverticulectomy only if ectopic mucosa is palpated in the diverticulum D. Meckel diverticulectomy only if an adhesive band to the umbilicus is present E. Meckel diverticulectomy only if previous signs of inflammation are present Most surgeons recommend removal in children when discovered incidentally at surgery Guidelines in adults: Age < 50 years Presence of palpable heterotopic tissue Diverticulum length > 2 cm Presence of a mesodiverticular band Signs of previous diverticulitis.

65 An intraoperative finding that is virtually pathognomic for Crohn’s disease is: A.Extensive stricturing of the small bowel B.Multiple interloop small bowel abscesses C.Multiple EC fistulas D.Terminal ileitis E.Extensive mesenteric fat wrapping

66 An intraoperative finding that is virtually pathognomic for Crohn’s disease is: A.Extensive stricturing of the small bowel B.Multiple interloop small bowel abscesses C.Multiple EC fistulas D.Terminal ileitis E.Extensive mesenteric fat wrapping

67 Which of the following is true regarding the principles of the operative management of the small bowel in Crohn’s disease? A.Optimal margin is at least 4 cm beyond grossly visible disease B.Frozen section should be obtained to confirm the absence of active disease in at least 1 margin C.Duodenal disease is best managed by resection D.A 10 cm strictured segment of jejunum can be managed by a Heineke- Mikulicz strictureplasty rather than resection E.Strictures longer than 10 cm are best managed by resection

68 Which of the following is true regarding the principles of the operative management of the small bowel in Crohn’s disease? A.Optimal margin is at least 4 cm beyond grossly visible disease B.Frozen section should be obtained to confirm the absence of active disease in at least 1 margin C.Duodenal disease is best managed by resection D.A 10 cm strictured segment of jejunum can be managed by a Heineke- Mikulicz strictureplasty rather than resection E.Strictures longer than 10 cm are best managed by resection H-M strictureplasty for ≤ 12 cm stricture Finney strictureplasty for ≤ 25 cm stricture Don’t forget to biopsy intraluminal ulcerations

69 The earliest lesion characteristic of Crohn’s is? A.Apthous ulcer B.Caseating granuloma C.Noncaseating granuloma D.Cobblestone mucosa E.Serosal thickening

70 The earliest lesion characteristic of Crohn’s is? A.Apthous ulcer B.Caseating granuloma C.Noncaseating granuloma D.Cobblestone mucosa E.Serosal thickening Superficial mucosal ulcers form from submucosal lymphoid follicle expansion

71 Which of the following is the best therapeutic option for mild active Crohn’s disease? A.Sulfasalazine B.Prednisone C.Budesonide D.Metronidazole E. Infliximab

72 Which of the following is the best therapeutic option for mild active Crohn’s disease? A.Sulfasalazine B.Prednisone C.Budesonide D.Metronidazole E.Infliximab Most commonly used drug for mild active disease is sulfasalazine Prednisone is treatment of choice for acute flare-ups Infliximab is used to maintain remission

73 All of the following are true regarding stromal tumors of the small bowel EXCEPT: A. They can be treated with tyrosine kinase inhibitors B. They stain positive for CD34 C. They typically present as large bulky tumors D. Surgical resection is the management procedure of choice E. Malignancy is primarily determined by evidence of local invasion

74 All of the following are true regarding stromal tumors of the small bowel EXCEPT: A. They can be treated with tyrosine kinase inhibitors B. They stain positive for CD34 C. They typically present as large bulky tumors D. Surgical resection is the management procedure of choice E. Malignancy is primarily determined by evidence of local invasion

75 The most useful indicators of survival/risk of mets are size of the tumor at presentation, mitotic index, and evidence of tumor invasion into the lamina propria Adjuvant treatment includes Gleevec (imatinib), a tyrosine kinase Inhibitor (unresectable/metastatic/recurrent) GISTs stain positive for CD34 (human progenitor cell antigen) and CD177 (c-kit proto-oncogene protein) Small bowel GISTs that present with symptoms tend to be very large and bulky Standard treatment is surgical resection with negative margins

76 Early postoperative small bowel obstruction: A. Is best managed nonoperatively in the majority of patients B. Is more frequent with upper intestinal than lower intestinal surgery C. Does not seem to occur after open transperitoneal aortic surgery D. Has a higher rate of strangulation than delayed small bowel obstruction E. Is associated with high morbidity and mortality rates

77 Early postoperative small bowel obstruction: A. Is best managed nonoperatively in the majority of patients B. Is more frequent with upper intestinal than lower intestinal surgery C. Does not seem to occur after open transperitoneal aortic surgery D. Has a higher rate of strangulation than delayed small bowel obstruction E. Is associated with high morbidity and mortality rates SBO seems to be more frequent with lower abdominal surgery Majority of pts. can be managed nonop Morbidity and mortality rates are very low

78 All of the following are true regarding Crohn disease EXCEPT: A. It is more common in individuals of low socioeconomic status B. It is the most common primary surgical disease of the small bowel C. It has a bimodal distribution D. It is more prevalent in smokers

79 All of the following are true regarding Crohn disease EXCEPT: A. It is more common in individuals of low socioeconomic status B. It is the most common primary surgical disease of the small bowel C. It has a bimodal distribution D. It is more prevalent in smokers Bimodal distribution (2 nd -3 rd and 6th decades of life) Risk factors include living in northern latitudes, Ashkenazi Jews, smoking, and familial inheritance Relative risk among 1st-degree relatives of patients with Crohn disease 14-15X greater than general population. More common in urban areas/high socioeconomic status

80 Which intestinal cells have been implicated in the formation of gastrointestinal stromal tumors A. Goblet cells B. Cajal cells C. Enteroendocrine cells D. Paneth cells E. Absorptive enterocytes

81 Which intestinal cells have been implicated in the formation of gastrointestinal stromal tumors A. Goblet cells B. Cajal cells C. Enteroendocrine cells D. Paneth cells E. Absorptive enterocytes Goblet cells secrete mucus Paneth cells secrete lysozyme, tumor necrosis factor, and cryptidins Enteroendocrine cells secrete various gut hormones

82 Which of the following is true regarding duodenal diverticula? A. They tend to occur on the antimesenteric side of the bowel B. They are usually true diverticula C. Treatment with endoscopic interventions is contraindicated D. They are most commonly located in the periampullary region E. When discovered incidentally at surgery, they should be left alone

83 Which of the following is true regarding duodenal diverticula? A. They tend to occur on the antimesenteric side of the bowel B. They are usually true diverticula C. Treatment with endoscopic interventions is contraindicated D. They are most commonly located in the 1 st portion of the duodenum E. When discovered incidentally at surgery, they should be left alone Most commonly (75%) located adjacent to the ampulla of Vater False diverticula that arise on the mesenteric border in areas of weakness in the bowel wall where blood vessels penetrate Asymptomatic in majority of pts, and surgery not recommended if incidentally discovered

84 Small intestinal lymphoma: A. Is most often the Hodgkin type B. Is associated with acquired immunodeficiency syndrome C. Most commonly occurs in the duodenum D. Is the most common small bowel malignancy E. Is primarily treated by chemotherapy

85 Small intestinal lymphoma: A.Is most often the Hodgkin type B. Is associated with acquired immunodeficiency syndrome C. Most commonly occurs in the duodenum D. Is the most common small bowel malignancy E. Is primarily treated by chemotherapy Predominantly non-Hodgkin type Small bowel lymphomas are a/w pts. w/ AIDS and transplant recipients Small bowel lymphomas most commonly involve the ileum (carcinoids) vs. adenocarcinomas in duodenum vs. GISTs evenly distributed throughout small bowel Primary treatment of small bowel lymphoma (as well as all other small bowel malignancies) is surgical resection including affected mesentery

86 A 68-year-old woman presents with an exacerbation of congestive heart failure and acute abdominal pain. Physical examination of abdomen is significant for mild diffuse abdominal tenderness but no rebound or guarding. CT arteriography of the abdomen demonstrates diffuse narrowing of the SMA and its branches. Which of the following is the best management option? A. Intravenous (IV) heparin drip B. Exploratory laparotomy C. Observation D. Intra-arterial papaverine E. Thrombolytic therapy

87 A 68-year-old woman presents with an exacerbation of congestive heart failure and acute abdominal pain. Physical examination of abdomen is significant for mild diffuse abdominal tenderness but no rebound or guarding. CT arteriography of the abdomen demonstrates diffuse narrowing of the SMA and its branches. Which of the following is the best management option? A. Intravenous (IV) heparin drip B. Exploratory laparotomy C. Observation D. Intra-arterial papaverine E. Thrombolytic therapy C/W nonocclusive mesenteric ischemia (20-30%) Seen in setting of decreased cardiac output (acute MI, CHF exacerbation or after cardiac surgery) For nonocclusive mesenteric ischemia, the treatment is medical optimization to improve cardiac output and selective intra-arterial infusion of a vasodilator (papaverine) into the SMA

88 Which of the following is the best test for prognosis and for monitoring treatment response in carcinoid tumors? A. Platelet serotonin levels B. A 24-hour urinary 5-HIAA test C. Serum chromogranin A levels D. Serum serotonin levels E. Neuron-specific enolase

89 Which of the following is the best test for prognosis and for monitoring treatment response in carcinoid tumors? A. Platelet serotonin levels B. A 24-hour urinary 5-HIAA test C. Serum chromogranin A levels D. Serum serotonin levels E. Neuron-specific enolase Serum chromogranin A is the most sensitive marker for detecting neuroendocrine tumors in general Most useful marker for detecting recurrence and response to treatment

90 The most important factor in reducing mortality from a small bowel fistula is: A. Early operative intervention B. Prevention of skin breakdown C. Waiting at least 6 weeks before operative intervention D. Control of sepsis E. Use of TPN

91 The most important factor in reducing mortality from a small bowel fistula is: A. Early operative intervention B. Prevention of skin breakdown C. Waiting at least 6 weeks before operative intervention D. Control of sepsis E. Use of TPN Primary cause of mortality from small bowel fistula is sepsis CT essential to ascertain whether fistula is being adequately captured and to rule out intraperitoneal abscesses Early management focuses on adequate fluid/electrolyte repletion, early institution of TPN, and skin protection

92 A 35-year-old man with recent travel to South America presents with fever, bloody diarrhea, and abdominal pain. On plain radiograph, there is free air under the diaphragm. At surgery, a single perforation is found in the terminal ileum with accompanying mesenteric lymphadenopathy and splenomegaly. Management consists of: A. Closure of perforation B. Segmental resection with primary anastomosis C. Ileocecectomy with ileal ascending colostomy D. Resection of terminal ileum with ileostomy and mucous fistula E. Resection of terminal ileum with right colectomy and ileotransverse colostomy

93 A 35-year-old man with recent travel to South America presents with fever, bloody diarrhea, and abdominal pain. On plain radiograph, there is free air under the diaphragm. At surgery, a single perforation is found in the terminal ileum with accompanying mesenteric lymphadenopathy and splenomegaly. Management consists of: A. Closure of perforation B. Segmental resection with primary anastomosis C. Ileocecectomy with ileal ascending colostomy D. Resection of terminal ileum with ileostomy and mucous fistula E. Resection of terminal ileum with right colectomy and ileotransverse colostomy C/W typhoid enteritis; Dx confirmed by positive blood or stool Culture Infection from Salmonella typhosa Perforation (peyer’s patches) typically solitary and in terminal ileum ; managed with simple closure and antibiotics

94 45 YO F with a h/o laparotomy and 5000 cGy of abdominal and pelvic irradiation for ovarian cancer 10 years ago presents with an acute bowel obstruction. CT scan shows a complete SBO at the level of the mid jejunum with no evidence of any masses. Which of the following is true about this condition? A. If a stricture is present, it is best managed by strictureplasty B. The patient should undergo a complete lysis of adhesions C. Chronic radiation enteritis is due to an obliterative arteritis D. A trial of corticosteroids is indicated E. The degree of radiation damage is not affected by whether the patient received chemotherapy

95 45 YO F with a h/o laparotomy and 5000 cGy of abdominal and pelvic irradiation for ovarian cancer 10 years ago presents with an acute bowel obstruction. CT scan shows a complete SBO at the level of the mid jejunum with no evidence of any masses. Which of the following is true about this condition? A. If a stricture is present, it is best managed by strictureplasty B. The patient should undergo a complete lysis of adhesions C. Chronic radiation enteritis is due to an obliterative arteritis D. A trial of corticosteroids is indicated E. The degree of radiation damage is not affected by whether the patient received chemotherapy Chronic radiation enteritis results from an obliterative arteritis of the submucosal vessels  submucosal fibrosis/stricture formation Strictureplasty not recommended b/c high risk of tissue breakdown Extensive LOA risks enterotomy and subsequent fistula formation Risk of radiation damage increases if pt. received chemo, has underlying vascular disease or diabetes

96 The most common cause of obscure GI bleeding in adults is: A. Small intestine angiodysplasia B. Meckel diverticulum C. Crohn disease D. Infectious enteritis E. Vasculitis

97 The most common cause of obscure (not seen on upper GI/ colonscopy) GI bleeding in adults is: A. Small intestine angiodysplasia B. Meckel diverticulum C. Crohn disease D. Infectious enteritis E. Vasculitis Small intestine angiodysplasia accounts for 75% of obscure GI bleeding in adults

98 All of the following are true regarding Peutz-Jeghers syndrome EXCEPT: A. The typical small bowel lesion is an adenomatous polyp B. It is autosomal dominant C. Bowel obstruction is the most common Presentation D. There is an increased risk of small intestine cancer E. There is an increased risk of breast cancer

99 All of the following are true regarding Peutz-Jeghers syndrome EXCEPT: A. The typical small bowel lesion is an adenomatous polyp B. It is autosomal dominant C. Bowel obstruction is the most common Presentation D. There is an increased risk of small intestine cancer E. There is an increased risk of breast cancer Features include mucocutaneous melanotic pigmentation and hamartomatous polyps (not adenomatous) of the small intestine Autosomal dominant inherited syndrome Most common symptom is recurrent colicky abdominal pain at significantly increased risk for development Gl tract cancers and extraintestinal cancers (testis, breast, uterus, ovary)

100 All of the following are true regarding pneumatosis intestinalis EXCEPT: A. In neonates, it is most often associated with necrotizing entercolitis B. It can lead to a nonsurgical pneumoperitoneum C. In adults, it is commonly a/w COPD D. Primary pneumatosis usually requires surgical intervention E. The diagnosis is readily made with plain radiography

101 All of the following are true regarding pneumatosis intestinalis EXCEPT: A. In neonates, it is most often associated with necrotizing entercolitis B. It can lead to a nonsurgical pneumoperitoneum C. In adults, it is commonly a/w COPD D. Primary pneumatosis usually requires surgical intervention E. The diagnosis is readily made with plain radiography Pneumatosis intestinalis is a radiographic finding and not a disease Divided into primary and secondary No specific treatment for primary Pneumoperitoneum can result from a benign case of pneumatosis intestinalis because the air-filled cysts are thin walled and can burst

102 THE END….


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